Diathermy hook for non-lap surgery
Diathermy dissection: While principles of open surgery should be applied to lap surgery, there are also some practices of lap surgery that can be extended back to open surgery.
Of course diathermy hook dissection is now well established in lap surgery, as two different techniques:
1. Hook and Cook, which pulls strands of tissue away from underlying structures to allow safe diathermy , for example exposing the cystic duct.
2. Paint and Push, where there is a kind of “dotted line” for dissection, for example separating gall-bladder from liver bed. [Perhaps someone has the secret for avoiding the occasional perforation of a thin gall-bladder at this stage].
The lap diathermy hook is typically blunt, which is a good safety precaution, because there is not the precise control of fine movement as in a “pen-holding grip” when the hand steadied on the work surface. Otherwise it might perforate fine structures.
In dissecting a mesentery or around the pancreas or axillary vein in open surgery, a much finer hook can be used. I hadn’t come across hook dissection in open surgery before my younger colleague tried it for the first time about 3 months ago. We now both recommend it as well worth trying. [He is a habitual diathermy dissector since a term in paediatrics some years ago].
By good luck, the only diathermy hooks available to fit ordinary Valley Lab handpieces in my hospital happen to be very fine ones, from a “Hyfrecator”.
Here are the dimensionss of the Valley Lab tip and the two hooks.
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Open Lap Hifrecator
tip hook hook
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length 20 mm 4.5 mm 3.7 mm
width 2.5 1.5 0.7
thick 0.4 1.0 0.6
ness
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One of the nice things about pulling and separating loose fatty tissue is the way it becomes “soda-water” tissue, with a lot of air in it, though less conductive. A lot depends on the wattage and on the rate at which the diathermy tip is moved along the tissue, say 5 mm a second or 20 mm a second. To those who find this nit-picking detail I apologize, but I think an appreciation of comparative figures is useful.
Another is that the diathermy tip, or hook, can be used like a simple dissector, pulling or pushing tissue apart. My experience of this is that hardly any operators take advantage of this technique. It is more useful with a hook.
I have been using Ethicon’s Harmonic Scalpel for a variety of laparoscopic and non-laparoscopic procedures. This device divides tissue with ultra-high frequency vibration creating a sort of “weld” of the surrounding tissue. It has two different handpieces- one is a hooked blade (5mm) and the other is a “pincher” (10mm) that has a rotateable blade with a sharp side, a dull side, and a flat side. One nice thing about it is that it has very little damage to surrounding tissue, so you can “hook and cook” with a substantially reduced chance of cutting into or damaging the adjacent structures such as gall bladder wall. It is excellent for indurated “no-plane” gallbladders, since the bleeding is so little, even if you slip over into the liver substance in the course of dissection. This device is cheaper than the way we would otherwise do it, since the handpiece is reuseable, and we don’t open a disposeable ConMed suction-irrigator-cautery. Additionally, with the “pincher” handpiece, this device will securely close blood vessels. I routinely use it for dividing short gastrics (when necessary) during lap Nissens, securing the cystic artery, and even for dividing the infundibulopelvic ligament and broad ligament during an LAVH or lap oophorectomy, which lets me avoid using the endo GIA i would otherwise use. A very useful device.
I do have a question for any readers that are also using the Harmonic Scalpel: What would be the feasibility of using it to divide and seal the cystic duct (eliminating the need to open a clip applier), or using it to divide and seal the appendix (eliminating the need to use an endo GIA, assuming you didn’t want to use an endo loop)?
I had used the Harmonic Scalpel twice for laparoscopic cholecistectomy.I used the hook only.One ventage: no smoke;other ,no posibilityes of burn in a site far of the operatory field; For coagulation and cut,I think that is not better that normal electrocautery.It’s need more time of contact and more traction that the classical electrosurgical.So,I think that it can’t work SAFE for seal the cystic duct or the appendix.However,I think that for the short gastric vessels,can be useful,but I can’t test this,because the Harmonic Scalpel was at my hospital only for demostration.
In my conversations with the representatives from Ethicon, division of the appendix was not recommended. I believe the strength of the coagulum created by the denaturation of protein with this energy source is dependent upon the type of tissue being coadapted. (Something to do with relative collagen content or something like that.)
I can personally attest to the danger of using this device to seal bowel. I was assisting a colleague during a laparoscopic splenectomy. During the take down of the short gastrics, the stomach was inadvertently grasped with the Harmonic Scalpel. The resulting gastric perforation was closed with a Endo-GIA.
I would have the same reservation about closing the cystic duct. Remember, stool and bile does not clot.
On the other hand, this is a wonderful device for dividing vascular tissue. It is very handy for taking down the lateral attachments of the rectum during a low anterior resection in a tight pelvis. (Either open or laparoscopic)
I may try it in the lab. Although don’t think it will be a good method of closing mucosal surfaces.